A 45 yo gentleman complained of a 3 month history of progressive loss of power in his legs. He more recently lost hand power; sphincter control was normal. On physical examination he looked healthy, but had pyramidal tract involvement of all four limbs, with brisk reflexes in the limbs (maseter reflex normal) and bilateral extensor plantar responses. There was no sensory abnormalities and gait was slightly spastic.
I immediately sent him for a cervical MRI, thinking of high spinal cord compression. It showed no cord compression but a T2-w high intensity linear image was seen in the ventral half of the spinal cord from C2 to C7 (Fig. 1). This was not visible in T1-weighted images and it not enhance. The spinal cord width was normal. TheNeurologist on duty diagnosed myelitis, and although the CSF was normal, gave the patient a bolus of methyl-prednisone. The brain MRI was normal.
On next day the patient developed tetraplegia with urinary retention. I reviewed the MRI with the neuroradiologists, and we noticed some punctiform signal void images in middle-lower cervical and upper dorsal subarachnoid space, mainly retrospinal (Fig. 1); after gadolinium these black points became white (Fig. 2).
Our diagnosis was an AV spinal malformation, probably a dural fistula. I decided to withdraw steroids. The patient underwent vertebral, cervical and dorsal spine angiography which were all normal. Meanwhile the patient was doing well without any treatment.
Finally, a diagnostic procedure was performed, the patient underwent a right carotid artery angiography in two different projections and magnifications (fig. 3 and 4): it shows a dural fistula whose feeding vessel is the meningo-hypophyseal trunk, arising from intracavernous ICA segment -cork-screw shaped arteries-; venous drainage is through spinal veins, which can be clearly seen (fig 5: cervico-dorsal segment).
Endovascular oclussion was attempted, without success. So the gentleman has been operated on; the feeding vessels have been coagulated, and tentorium severed. There is no yet postsurgical angiography. Patient is now in the Rehabilitation Departement and has a middle paraparesis.
Jose Maestre M.D.
Hospital Virgen de las Nieves